FPs Can Play Key Role in Treating These Patients

U.S. veterans suffering from posttraumatic stress disorder (PTSD) have a new battle waiting for them when they return home, but family physicians are well-positioned to aid them in the fight.

A recent study(jama.ama-assn.org) in JAMA: the Journal of the American Medical Association, investigated the effect of mental health disorders, such as PTSD, on the risks and adverse clinical outcomes associated with prescription opioid use. The study concluded that soldiers returning from Iraq and Afghanistan who have such mental health diagnoses, particularly PTSD, are at an "increased risk of receiving opioids for pain, high-risk opioid use and adverse clinical outcomes."

According to the study authors, returning combat veterans likely will be visiting primary care physicians in large numbers, and extra care should be taken when prescribing opioids to relieve physical symptoms.

"These patients may benefit from biopsychosocial models of pain care, including evidence-based nonpharmacologic therapies and nonopioid analgesics," the authors wrote. "Integrated treatments that target both mental health disorders and pain simultaneously are effective for both problems and may decrease harms resulting from opioid therapy."

The study also noted that the association between PTSD and opioid prescription -- which it found to be especially robust -- proved to be significant for all subgroups of veterans with PTSD.

story highlights

A study in JAMA: the Journal of the American Medical Association, indicates soldiers returning from Iraq and Afghanistan who have mental health diagnoses, especially those with posttraumatic stress disorder (PTSD), are at an "increased risk of receiving opioids for pain, high-risk opioid use and adverse clinical outcomes."

With returning combat veterans presenting to primary care physicians in large numbers, extra care should be taken when prescribing opioids to relieve physical symptoms.

According to one FP expert, however, when opioid therapy is administered to service members shortly after acute injury during combat, it can actually reduce their risk of developing PTSD.

"Veterans with mental health diagnoses (who were) prescribed opioids, especially those with PTSD, were more likely to have comorbid drug and alcohol use disorders; receive higher-dose opioid regimens; continue taking opioids longer; receive concurrent prescriptions for opioids, sedative hypnotics, or both; and obtain early opioid refills," the authors wrote. "Finally, receiving prescription opioids was associated with increased risk of adverse clinical outcomes for all veterans returning from Iraq and Afghanistan, especially for veterans with PTSD, who were at highest risk of alcohol-, drug-, and opioid-related accidents and overdose, as well as self-inflicted injuries."

According to FP Jeffrey Sonis, M.D., M.P.H., of Chapel Hill, N.C., family physicians are in a unique position to help these veterans.

"From the article, I think it is reasonable to draw the conclusion that primary care docs should be careful about prescribing opiates to returning service members with PTSD, since they are more likely to demonstrate high-risk use of opiates -- such as using higher doses, obtaining early refills and receiving concurrent sleeping medications -- and more likely to have adverse outcomes, such as opioid-related injuries and alcohol and drug overdoses," said Sonis.

The study authors said their findings support improving care of patients with comorbid pain and PTSD because of the heightened risk of self-medication with opioids and substance abuse in veterans with PTSD, which may result in further declines in interpersonal and occupational functioning.

"Trials assessing the efficacy of opioids in treating chronic noncancer pain have shown only modest or equivocal benefit," the authors wrote. "In contrast, multiple studies have described numerous harms, including overdose death, from the upsurge of opioid prescribing in recent years."